Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
Do you take any special considerations for a patient with ESKD who has an ileostomy/colostomy and wishes to start peritoneal dialysis?
My special considerations are to probably avoid PD. But it depends on what the surgical history was for that ileostomy or colostomy, e.g., there may be a lot of scar tissue. When PD works (flows easily in and out), it works; when it doesn',t it doesn't and if doesn't it usually doesn't get better (4...
What is your calcium level threshold for initiating targeted calcium lowering therapies for patients with an acute kidney injury believed secondary to renal vasoconstriction and volume depletion?
Treatment of hypercalcemia should be based on the severity of the symptoms rather than any arbitrary calcium level threshold. Therefore, if the AKI is due to hypercalcemia-induced renal vasoconstriction and volume depletion, then the hypercalcemia should be treated.
How often do you monitor urine protein levels for patients with membranous nephropathy for whom you initiate obinutuzumab?
Most studies of obinutuzumab in membranous nephropathy are retrospective, with remission rates of up to 83%. Would monitor UPCR every 1-3 months and check PLA2R every 3 months. Immunological remission (negative PLA2R) precedes clinical remission (one study with 76% at 3 mo and 80% at 6 mo), and clin...
Would you recommend adjusting the hemodialysis schedule for a TTS dialysis patient who is scheduled for surgery on a Monday?
It depends on the patient. If the patient has no residual renal function, it’s prone to volume overload or hyperkalemia; such a patient would benefit from a dialysis session on Monday before surgery. If the patient is recently initiated on iHD, or has good volume control and electrolytes are fine, y...
Do you recommend patients with ESKD time their daily B complex multivitamin to after hemodialysis on hemodialysis days?
Yes. B vitamins do get removed some with dialysis but their removal is limited. Vitamin C on the other hand seems to be removed better. I don't see any harm of taking them after dialysis.
How do you approach the use of genetic testing in patients older than 30 years with resistant hypertension and hypokalemia, but with a normal aldosterone to renin ratio and no known family history of hypertension?
I am starting to use genetic testing more frequently now on patients like this, even though the absence of family history makes monogenic HTN less likely. Once other causes of hypertension with hypokalemia (Cushing syndrome, ectopic ACTH, licorice, etc.) are excluded, I think genetic testing may hel...
What is your approach for stone prevention for patients with recurrent nephrolithiasis who are started on GLP-1 agonist therapy and subsequently consume less daily water intake?
There is no approach except clinical interaction to promote continued fluid intake. I have personal experience with this kind of problem and believe one can achieve a reasonable response - albeit it can require some increase in visits.
What factors would lead you to consider revascularization in a patient with bilateral renal artery stenosis between 50-70% who has persistently uncontrolled hypertension despite maximal medical therapy?
Several randomized controlled trials (RCTs) (STAR 2009, ASTRAL 2009, CORAL 2013) have shown that medical therapy has similar outcomes to revascularization (stenting) in patients with 50-70% renal artery stenosis (RAS). In these RCTs, serious complications of the interventional procedures occurred in...
How would you tailor immunosuppression in an elderly patient presenting with primary FSGS?
Would use less [or avoid] high dose glucocorticoids. Rituximab would be preferred approach. Other options include CNIs and MMF.
What are some practical tips for when a patient's consistently stated goals of care do not correlate with their actions?
First, it's important to remember that most of us have inconsistent beliefs. We both want to lose weight, and we want to eat chocolate cake; we want to get an A, and we want to go to the party. So when we see inconsistencies in others' beliefs, rather than being judgmental, we should get curious. Ou...